Case Management - Nurse, Senior
Company: Blue Shield of California
Location: Young
Posted on: June 29, 2025
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Job Description:
Your Role The Care Management team will serve to support the
mission of the department, which is to provide support to patients
in maintaining health and wellness in the outpatient setting. The
Case Management – Nurse, Senior will report to the Manager of Care
Management. In this role you will play a pivotal role in assessing
member needs, providing clinical education, as well as care
coordination with providers, medical groups, and community
resources. You will be responsible for managing and coordinating
patient care, ensuring that our members receive the highest quality
of care and services. Care Managers perform care management (CM)
activities demonstrating clinical judgement and independent
analysis, collaborating with members and those involved with
members’ care including clinical nurses and treating physicians.
Your Work In this role, you will: Determine appropriateness of
referral for CM services, mental health, and social services Assess
members health behaviors, cultural influences and clients
belief/value system. Evaluate all information related to
current/proposed treatment plan and in accordance with clinical
practice guidelines to identify potential barriers Research and
design treatment/care plans to promote quality of care, cost
effective health care services based on medical necessity complying
with contract for each appropriate plan type. Adjust plans or
create contingency plans as necessary Identify appropriate programs
and services that align with member needs and preferences Initiate
timely Individualized Care Plans (ICP) based on Health Risk
Assessment (HRA) completion, participation in and documentation of
Interdisciplinary meetings (ICT), assisting in transitions of care
across all ages Provide Referrals to Quality Management (QM),
Disease Management (DM) and Appeals and Grievance department (AGD)
Conduct member care review with medical groups or individual
providers for continuity of care, out of area/out of network and
investigational/experimental cases Research opportunities for
improvement in assessment methodology and actively promote
continuous improvement. Anticipate potential barriers while
establishing realistic goals to ensure success for the member,
providers, and BSC Determine realistic goals and objectives and
provide appropriate alternatives. Actively soliciting client’s
involvement Recognize need for contingency plans throughout the
healthcare process Provide education and support to members and
their families regarding health conditions, treatment options, and
community resources Follow up with members as appropriate to ensure
they have successfully connected with recommended programs and
services Your Knowledge and Experience Requires a current and valid
CA RN License or valid RN license(s) from other state(s). Preferred
licensure from a compact state. If assigned to another state, must
maintain an active, unrestricted RN license in assigned state(s) or
the ability to obtain required RN license (in addition to primary
state license) within 90 days of hire Bachelor of Science in
Nursing or advanced degree preferred Certified Case Manager (CCM)
Certification or is in process of completing certification when
eligible based on CCM application requirements Requires 5 years
experience in nursing, healthcare, or related field A minimum of 3
years managed care experience in inpatient, outpatient, or managed
care environment preferred Health insurance/managed care experience
preferred Transitions of care experience preferred Strong knowledge
of healthcare delivery systems, managed care principles, and care
coordination Excellent communication skills
Keywords: Blue Shield of California, Mesa , Case Management - Nurse, Senior, Healthcare , Young, Arizona
